First Steps to Patient-Centered Care: Meaningful Use Focuses Industry on Baby Steps

By Chris Dimick

It is hard to say just what patient-centered care is, but just about everyone agrees that we lack it. The meaningful use program has focused providers, vendors, and consumer advocates around some basic first steps.

This January the meaningful use program began, and with it launched a set of measures requiring participating hospitals and professionals to make their health IT systems a little more patient friendly. Among the program criteria that participants must meet are several focused on better engaging patients in their care by making their health information more accessible to them.

The requirements represent a shift in focus for health IT, which traditionally has been designed to capture and retrieve data for providers, not share it with patients.

The meaningful use measures come from the Department of Health and Human Services, where a patient-centric philosophy has been ingrained in recent work at the Office of the National Coordinator for Health IT. Much of ONC's patient-centric work is included in the meaningful use program, which offers Medicaid and Medicare incentives to professionals and hospitals who use EHRs to meet care objectives.

ONC recognizes that no matter how much money is poured into health IT, systems designed for providers will have only a limited potential to improve health processes and outcomes, says Josh Seidman, director of meaningful use at ONC.

While many agree the work being done by ONC through the HITECH Act and the meaningful use program has vast potential to affect the healthcare system, it is still unclear whether these first patient-centric steps will have a strong impact.

Some patient advocates say that while stage 1 meaningful use is a start for helping engage patients, ONC and the healthcare system still have several leaps to make before patients feel the effects.

Unprecedented Opportunity

While the healthcare industry has relied heavily on technology for years, those technologies historically have not interfaced with the people receiving care.

This disparity disconnects patients from the healthcare system, and it creates a huge challenge in now bringing patients into the established technological system, says Alison Rein, a former health consumer advocate at the National Consumers League and current director with AcademyHealth, a research and policy advisory group based in Washington, DC.

"There has been a total bifurcation of experience, and we are starting to recognize that that is not serving our needs or our interests," Rein says.

Seidman sees meaningful use as an unprecedented shift in health IT focus that can help address this disconnect.

"Clearly there is an opportunity here that we have never had," Seidman says. "There is a lot of opportunity to ensure that as providers meaningfully use EHRs, they are using them in a way that is patient centered."

The ONC meaningful use initiative is still in its early stages. The first professionals and hospitals will begin reporting their measures in April. It will take longer to determine its impact on patients.

Characteristics of Patient-Centered Care

Patient-centric healthcare can be difficult to describe. There is not much evidence to define just what types of healthcare or health IT systems positively impact patients and engage them in their care, Rein says.

However, three characteristics of patient-centric care have emerged. A patient-centered healthcare system gives patients the ability to communicate effectively and immediately with their providers. It provides patients access to information that is important and useful for them, when they need it.

Finally, patient-centered health IT allows providers to look holistically at an individual and treat them through the coordination of other providers.

"There are a number of other things you can build onto that, but we are still at the very, very beginning of what I imagine will be a huge innovation curve," Rein says. "At this point we are not exactly sure what, truly, patient-centered healthcare is.

"I think everybody just agrees that we don't really have it."

Stage 1 Builds a Foundation

Both patient advocates and ONC agree that the patient-centric elements included in the first stage of the program could improve the way patients interact with their providers and the healthcare system. But whether these measures went far enough in requiring providers to engage patients is open to debate.

There are several stages planned for the meaningful use initiative, with each stage expected to increase in difficulty for providers. ONC considers stage 1 merely the start of their efforts to move American healthcare and healthcare IT toward delivering patient-centric care.

"I do think, as with many things in the stage 1 meaningful use final rule, there is some very tangible impact," Seidman says. "But the greater impact is laying the foundation for what will come in the future."

The first stage of the program features five outcome priorities, one of which is "engage patients and families in their health care." Within this category are objectives and corresponding measures, some of which are mandatory and some of which are optional (see the table below). Each objective has a measurement that defines its successful completion.

The Stage 1 Objectives and Measures

In all, The meaningful use program includes 27 objectives. Eligible professionals must meet 20 objectives, and eligible hospitals must meet 19.

The requirements related to patient-centered care are grouped under the health outcomes priority "engage patients and families in their health care." Two patient-engagement objectives for professionals and two for hospitals fall within the "core" set of objectives. These objectives must be met. Two additional objectives for professionals and one for hospitals appear in the "menu" set. These objectives are not mandatory. Program participants have flexibility to choose five of the 10 objectives in the menu set. It is expected that all objectives in the menu set will become mandatory in stage 2 of the program.

More than 50% of all patients of the EP or the inpatient or emergency departments of the eligible hospital or CAH (POS 21 or 23) who request an electronic copy of their health information are provided it within 3 business days

Provide patients with an electronic copy of their discharge instructions at time of discharge, upon request

More than 50% of all patients who are discharged from an eligible hospital or CAH's inpatient department or emergency department (POS 21 or 23) and who request an electronic copy of their discharge instructions are provided it

Provide clinical summaries for patients for each office visit

Clinical summaries provided to patients for more than 50% of all office visits within 3 business days

Menu Set

Objectives

Eligible Professionals

Eligible Hospitals and Critical Access Hospitals

Measures

Provide patients with timely electronic access to their health information (including lab results, problem list, medication lists, medication allergies) within four business days of the information being available to the EP

More than 10% of all unique patients seen by the EP are provided timely (available to the patient within four business days of being updated in the certified EHR technology) electronic access to their health information subject to the EP's discretion to withhold certain information

Use certified EHR technology to identify patient-specific education resources and provide those resources to the patient if appropriate

Use certified EHR technology to identify patient-specific education resources and provide those resources to the patient if appropriate

More than 10% of all unique patients seen by the EP or admitted to the eligible hospital's or CAH's inpatient or emergency department (POS 21 or 23) are provided patient-specific education resources

In order to meet this objective, professionals must provide this information within three business days in electronic form to 50 percent of patients who request it.

This is a big step toward providing patients with easy, electronic access to their health records, but it is still just a start, according to Christine Bechtel, vice president of the National Partnership for Women & Families, based in Washington, DC. Bechtel was appointed to the ONC Health IT Policy Committee by the Government Accountability Office to serve as a patient advocate, and she also serves on the committee's meaningful use workgroup. Both entities develop recommendations on the meaningful use criteria for ONC, with Bechtel serving to ensure patient interests are maintained throughout the process.

The electronic access measure and other stage 1 patient-centric outcomes help lay the groundwork for requiring providers to offer patients online access to their personal health information, Seidman says.

One of the optional objectives for professionals requires them to provide patients with timely electronic access to their health information within four business days of the information being available to the provider.

This would likely be met by offering patients an online portal where they could view information like lab results, problem lists, and medication lists. However, it could be met by e-mailing the information or providing it on portable media, such as a CD.

Providing patients timely, electronic, and direct access to their information has the potential to vastly improve a patient's engagement in their healthcare, Seidman says.

"There is certainly an expectation now that patients have much more timely access to their electronic data than they previously would have had," he says. "There are requirements under HIPAA that require providers to provide records to patients, but that used to be a matter of weeks. Now it is a matter of days.

"It is an important paradigm shift, because if there is something serious going on in terms of your own health, there is a big difference between a few days and a few weeks."

Stage 1 not only helps improve patient access to their health information, but it also helps patients better understand their information. One optional objective requires providers use EHR technology to identify patient-specific education resources and provide those resources to the patient.

For example, a patient diagnosed with diabetes would have a diagnosis code generated in the EHR that then links to educational content on how to manage diabetes. This information is then provided to the patient through a secure portal or sent via e-mail.

Software exists to enable this process. The National Library of Medicine recently created open source software called MedlinePlus Connect that enables providers to use their EHRs to link ICD or diagnosis codes to specific health information, Seidman says.

Was a Foundation Enough?

While most agree that the meaningful use patient-centric objectives were a positive step toward better engaging patients in healthcare, others point out the limited reach of the objectives' actual measures.

A majority of the patient-centric objectives are included in the menu set of stage 1, where participants need select only five of the 10 options. Some patient advocates commented to ONC that these patient-centered outcomes should have been in the required core set.

In addition, many of the patient-centric measures require physicians provide the service to 50 percent or fewer of their patients. Only 10 percent of an eligible professional's patients are required to receive electronic access to their health information within four business days. Hospitals are entirely excluded from the objective.

The final objectives and measures are a weaker set than those put forth in the proposed meaningful use rule. The original measures set higher standards but were lowered after industry comments claimed they were too ambitious. In addition, all objectives were required in the proposed meaningful use rule.

Rein notes that the scope of the objectives themselves has limited reach. "Gaining access to information isn't enough to generate 'patient-centered care,'" Rein says. "It is a significant portion, but it is one piece."

Truly redesigning the healthcare system to make it patient-centric is going to require more than just the "information generation delivery component" that came out of stage 1 meaningful use, she says.

Seidman asks that people be patient with the program.

Developing stage 1 measures required ONC committees to perform a tricky balancing act. If they made the measures too easy to meet, then healthcare outcomes would not significantly improve. If they made the measures too difficult, providers would not participate in the program.

What stage 1 primarily has done is formally encourage providers to change their once self-centric mindset when it comes to the use of health IT, Seidman says. Getting providers to use their systems for patient-centric activities is a major win for patient advocates and a large shift in industry mentality.

In the past EHRs were built for providers, and patient access to information was an afterthought, Seidman says. Now the expectation is shifting, and patient concerns and access to data are being considered in EHR design. Stage 1, he says, laid an "important foundation for that change to happen."

Not including patients in health IT from the beginning was a "market failure" that many stakeholders, including ONC, are now trying to correct, Rein says. Stage 1 won't solve this problem, but it is a significant move toward reorienting the healthcare system.

"You can't create world peace in a day," Rein says. "[ONC] is wise to be doing it in a step-wise fashion… It's too early to tell whether stage 1 was enough or not enough."

During the policy committee's stage 1 meaningful use discussions, Bechtel says she focused on developing measures that improve provider care coordination and patient communication with providers-the two biggest problems patients face in the healthcare system.

But while stage 1 was a good start, the measures "didn't go quite far enough," she says.

"And that was by design, because the policy committee and ONC agreed that we needed to not ask for everything up front and have it be impossible so that no one participates in the program."

The optional stage 1 patient-centric menu items need to become core requirements in stage 2, Bechtel feels, in order for patients to further become engaged in their care through the initiative.

"Stage 1 in many ways was a big victory, because we could have ended up with a set of criteria that had no patient and family engagement dimensions at all," she says. "And we have a whole domain on patient and family engagement; we have made some strides in care coordination and information exchange and quality and reducing disparities."

Some providers feel stage 1 meaningful use is too difficult. Reproducing electronic copies of health records can be a challenge for many older and some recent EHR systems. Creating an electronic copy within three days, as included in a stage 1 measure, is even more difficult.

While developing stage 1 criteria, Bechtel says the Health IT Policy Committee heard from vendors and providers who said their system would be unable to meet some of the criteria. However, Bechtel sees that as evidence that challenging criteria are necessary, not that they should be eliminated.

"The healthcare system today is not delivering the quality of patient-centered care that we know the individuals that comprise the healthcare system are capable of," she says. "So we do need to retrofit our information technology systems to be able to deliver more meaningful care for patients."

Stage 2 to Raise the Bar

Stage 2 of the meaningful use program, set to begin in 2013, will increase the amount of patient-centric measures required of providers, Seidman says.

While the stage 2 criteria are still being developed by ONC's Health IT Policy Committee and Meaningful Use Workgroup, some general details have emerged.

The committee has discussed emphasizing measures that allow patients to view and download their health information.

Stage 1 raised the expectation that providers give patients electronic access and speedy copy rights to their records. Stage 2 will likely stiffen that requirement, calling for providers to allow patients to view their records online and download them for use in managing their health.

The intent is that "patients can start to download and move their information around the healthcare system so it follows them and is available when and where it is needed most," Bechtel says. "That is truly one of the most patient-centered things we could do."

Other patient-centric stage 2 criteria may include providing patient-provider secure online messaging, granting patients real-time access to their data, and integrating patient-reported data into systems. Examples include electronically obtaining patient feedback on care and allowing patients to generate data from home through biometric devices that report to a provider's EHR.

Strengthening the health information exchange aspects of meaningful use in stage 2 also must be a priority, Bechtel says. More quality measures reflecting how effectively health IT is improving care are also expected in later stages.

"It is clear that for stage 2 we have to advance those [patient-centered] criteria, and my hope is that ONC will," Bechtel says. "We have to advance them in a way that reorients the system around patients and empowers patients to become even more active in their health and in their care."